Analysis Nautical Charts and Bathymetric Surveys Figure1.Approximate outline of 5 m isobath 1992, 1996, and 1998. Comparison of the bathymetric surveys of 1992, 1996, and the post-occurrence survey of 1998 showed that, over the years, the edge of the shoal at the entrance to the shipyard basin has extended westward as a result of silting (seeFigure1). In keeping with good seamanship, navigating personnel and the pilot chose to use the largest-scale chart as a reference. However, this chart did not bear any notice or warning concerning silting off the shipyard. Although bathymetric surveys provide more detailed depth information than nautical charts, they are not normally used for navigation. They are usually intended for those who monitor the depth of navigable waters. A note to this effect was included on most of these documents. However, the pilot took into account the 1992 survey in his manoeuvring. As the shipyard had not submitted the 1996 survey to the CHS, neither the pilot nor the CHS had consulted it. It seems that there are no standards for the submission of bathymetric surveys performed by the private sector if no construction, dumping or excavation work is done. The accuracy of bathymetric surveys depends on several factors related to sounding and survey quality. When the sea bed is subject to constant silting, surveys only represent the actual sea bed at the time of the soundings. Neither the 1992 nor the 1996 bathymetric survey showed the presence of the 3.8-mridge. As no nautical chart or bathymetric survey available indicated the presence of this ridge, navigating personnel and the pilot could not accurately assess the available depth under the vessel's keel near the approaches to the shipyard. Choice of Navigation Aids As the weather was clear, the vessel was conducted visually. The pilot chose to use as visual cues the MCTS radar tower and the yellow tower at the end of the basin. As the CHS had not received any notice from pilots that the yellow tower was used as a landmark, it had neither listed nor charted it. Furthermore, the tower is not located at the centre of berth No74, but northwest of that position. Accordingly, the alignment that it forms with the MCTS tower runs northwest of the centre of the basin's entrance in the approaches. Examination of the alignment shows that the lateral error 200m from the basin's entrance is about 15m. As a result, the alignment gives the navigator only an approximation of the vessel's approach track. To assess the vessel's way, the pilot observed the radio towers in way of Fort No1 at Pointe de Lvy. Although the transverse visual cues were less crucial in determining the vessel's position, their location and number differ from what is shown on CHS chart No1316. Discussions with the DFO Technical Services Branch revealed that there was no mechanism to advise the CHS of any positional or physical change to these radio-electric installations. The change in the location of the towers is not a factor that contributed to the grounding, but it could jeopardize safety in other instances. The CHS endeavours to present information useful to mariners, but some charted landmarks are more useful than others. Charted features are not all plotted with the same level of accuracy. At the time of this occurrence, the mechanism for exchanging information with navigators, including pilots, did not appear to bring about the desired outcomes. Although there are no standards governing the choice of landmarks to be charted, the participation of the marine industry in making its requirements known could improve the quality of such choices. Approach Manoeuvre The method used in approaching Murphy wharf can vary from pilot to pilot. The pilot on duty chose a manoeuvre that he had used in the past, which he hoped would minimize the unexpected and increase safety. He planned to approach the mole of berth No75 and drift transversely towards the centre of the basin and then drift again transversely towards Murphy wharf. Nothing suggests that the drift produced by the vessel's bow thruster and the tug was not under control. Before grounding, the vessel was making slow headway while drifting transversely to the south area. At about 0215, the pilot noticed that the vessel was motionless; he must have concluded that it had made contact with the sea bed. Figure2.Approximate position of vessel over 3.8-m ridge The underwater inspection showed that the damage was confined to the bottom plating, especially in way of the port bilge strake. It may be concluded from this damage that the vessel was moving transversely when it struck an object on its port side. The3.8-mridge is the only object northwest of the 5-m isobath and southeast of the vessel's course (seeFigure2). With a water level ranging from 4.1m to 3m during the grounding, this ridge was most probably the object that the FederalFraser struck. It is conceivable that the depth of water over the ridge was less than or equal to 3.5m before the vessel's impact and that the depth over it increased to 3.8m as a result of contact with the vessel. Based on the distance measured by radar, 0.15nautical mile (278m), and the estimated distance of 200m between the bow and the radar antenna, the vessel's bow would have approached within about 78m of the mole of Murphy wharf. An examination confirmed that the ridge is about 75m from Murphy wharf. The contact of the stem with the shoal would have been sufficient to check and then stop the vessel. The information from ship sources and yard employees' observations confirm that the vessel stopped moving around 0200 about the same distance off the wharf. The subsequent manoeuvring speed changes caused the vessel to advance farther onto the ridge. As the water level fell, the hull's weight on the ridge would have caused scoring on the plating. The scoring between 30m and 75m from the bow confirms the 30m and 40m distances reported by the chief officer. The approximate position of the grounding in way of the 3.8-mridge shows that the vessel had drifted southeast of the alignment of the radar and yellow towers and that she was lined up approximately in the centre of the basin as reported. Navigating personnel did not use the parallel index technique on one of the radars. A voyage plan using this radar technique could have enabled the navigators to safely determine the vessel's alignment and distance off the shoal without having to plot positions on the chart. Had the yellow tower been charted, the alignment of the yellow tower with the radar tower could have been on the radar screen, and parallel indexing could have been employed. On this alignment, the vessel would have entered the basin without striking the 3.8m ridge. Without this yellow tower, navigating personnel could have used the mole of the Murphy wharf. Bridge Resource Management A crew sailing in foreign waters generally has little local knowledge. As a result, navigating personnel tend to let the pilot assume entirely the conduct of the vessel. Because the ship's navigating personnel were not actively involved in the vessel's navigation in the approach to the basin, they did not realize that the vessel had run aground until well after the fact. Although the vessel did not lose its watertight integrity, the initiation of shipboard damage assessment measures was delayed. Although the pilot had talked about the manoeuvre he intended to execute, this occurrence shows that, at the time of the grounding, full and complete participation was not established between navigating personnel and the pilot. To ensure a safe approach, exchange of information among bridge team members must be continuous. Reporting of a Marine Occurrence The MCTS Centre should be advised of marine accidents promptly. The Centre is the point of contact for organizations responsible for initiating emergency measures. Such organizations, like the DFO and Transport Canada, are mandated to, interalia, protect the environment and ensure the seaworthiness of vessels. VHF Radiotelephone Practices and Procedures Regulations set out the navigation safety call measures to be undertaken to inform MCTS and other mariners operating in the area in order to promote safe navigation after an occurrence takes place. Operational radiotelephones were available for making a navigation safety call, but were not used. Because MCTS was not informed of the grounding, the implementation of shore-based and shipboard damage assessment measures was delayed. In addition, mariners transiting the area were unaware of information that could have affected their navigation. The FederalFraser was visible from the MCTS Centre; it was on the radar screen, but the vessel's return to the anchorage after the failed attempt to dock did not arouse the marine traffic regulator's curiosity. Having been informed of the occurrence, the regulator did not obtain all relevant information as set out in the MCTS operations manual. While not all responsible organizations were required in this occurrence, not acquiring relevant information as soon as possible can cause critical delays in the provision of emergency services. In this instance, the pilot and navigating personnel were not aware of the mandated responsibilities that certain government departments must undertake after being informed of a marine occurrence by MCTS, and thus did not report the occurrence to the MCTS. Sound bridge resource management practices (i.e. the full and complete cooperation necessary for a safe approach) was not established between the vessel's navigating personnel and the pilot. Communication between navigating personnel and the pilot was interrupted, and position fixing methods, such as radar parallel indexing, were not employed to determine the ship's position. On approach to Murphy wharf, the pilot utilized, as a beacon range, an uncharted feature that did not support visual fix plotting on CHS chart No1316. This choice increased the possibility of navigational error. Neither the vessel's navigating personnel nor the pilot had access to a 1996 privately-contracted bathymetric survey which confirmed the presence of silting. The newly formed 3.8-mridge on which the vessel ran aground was detected during a post-occurrence sounding.Findings as to Causes and Contributing Factors Sound bridge resource management practices (i.e. the full and complete cooperation necessary for a safe approach) was not established between the vessel's navigating personnel and the pilot. Communication between navigating personnel and the pilot was interrupted, and position fixing methods, such as radar parallel indexing, were not employed to determine the ship's position. On approach to Murphy wharf, the pilot utilized, as a beacon range, an uncharted feature that did not support visual fix plotting on CHS chart No1316. This choice increased the possibility of navigational error. Neither the vessel's navigating personnel nor the pilot had access to a 1996 privately-contracted bathymetric survey which confirmed the presence of silting. The newly formed 3.8-mridge on which the vessel ran aground was detected during a post-occurrence sounding. Since the 1996 private bathymetric survey was not subsequent to works, such as construction, dumping, or excavation, the results were not required to be forwarded to the Navigable Waters Protection Division and were not available to navigators. The 1996 bathymetric survey was conducted for operating purposes; since the shipyard is located in a private sector of the port, there was no obligation to report changes to the local port authority. At the time of the accident, the mechanisms for the exchange of information between CHS and navigators, including pilots, were not generally known. The CHS had not been informed of all landmarks used by pilots and thus, it could not prioritize the selection of landmarks to be charted in order to facilitate the safe passage of vessels in restricted waterways.Findings as to Risk Since the 1996 private bathymetric survey was not subsequent to works, such as construction, dumping, or excavation, the results were not required to be forwarded to the Navigable Waters Protection Division and were not available to navigators. The 1996 bathymetric survey was conducted for operating purposes; since the shipyard is located in a private sector of the port, there was no obligation to report changes to the local port authority. At the time of the accident, the mechanisms for the exchange of information between CHS and navigators, including pilots, were not generally known. The CHS had not been informed of all landmarks used by pilots and thus, it could not prioritize the selection of landmarks to be charted in order to facilitate the safe passage of vessels in restricted waterways. Immediately following the vessel's grounding, neither navigating personnel nor the pilot utilized a maritime radiotelephone to transmit a navigational safety call or to report the accident to MCTS. Not doing so resulted in delays in notifying shore-based responsible organizations for conservation of the environment.Other Findings Immediately following the vessel's grounding, neither navigating personnel nor the pilot utilized a maritime radiotelephone to transmit a navigational safety call or to report the accident to MCTS. Not doing so resulted in delays in notifying shore-based responsible organizations for conservation of the environment. Safety Action Action Taken Following the grounding, the Corporation des pilotes du Bas Saint-Laurent asked DFO to conduct a survey of the approaches to the shipyard. On 18September1998, the CCG conducted soundings. On 30November1998, the CHS produced the bathymetric survey entitled Quai de MIL Davie Lauzon, No321/1018. After learning that the number and positioning of the radio communication towers located west of Fort No1 at Pointe de Lvy had changed, the DFO Technical Services Branch, Laurentian Region, amended its policy so that any changes to its property will be made known to the CHS. In 1999 the shipyard awarded a contract for a full bathymetric survey of the shipyard approaches. According to the Navigable Waters Protection Division of the Marine Program Branch at the Department of Fisheries and Oceans, no dredging activity was conducted in the area of the grounding. In December 1999, the TSB issued two marine safety information (MSI) letters dealing with the shortcomings identified during the investigation. MSI03/1999 deals with the failure to report the grounding of the FederalFraser and to use a VHF radiotelephone; MSI04/1999 informs the CHS of the shortcomings concerning the unreported shoal, the non-standard 1996 bathymetric survey, the use of uncharted landmarks, and the failure to report features used by pilots for navigation. CHS took action in connection with the note on CHS chart No1316 regarding the silting for the shipyard area. In June2001, CHS produced this note which was later published on CHS chart No1316. CHS is proposing to also include, in its 2002 agenda, formal meetings with industry and the St.Lawrence pilotage organizations in order to determine their requirements and improve quality control with respect to information exchange mechanisms so that useful navigation information may be better presented and thus, expected outcomes may be obtained.